Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Wednesday, October 07, 2009

Sampler

Moving this post once again to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, it's been my goal to let people into the operating room, and into the life and thoughts of a surgeon; to share my take on some surgical conditions, and sometimes just to get a laugh.

Memorable Patients: I've told stories about people who made a big impression

here, (the most stool I've ever seen in a belly)here, (when my partner got sick)here, (she killed her caregiver, and almost killed herself)here, (thirteen years old, and I couldn't save her)here, (until the end, she kept bringing me food)here, (kidney cancer in his pancreas, and he kept on truckin')here, (bleeding so fast, I could hear it)here, (no stomach, kept eating steak)here, (breast-heart connection?)here, (an extreme test of faith)and here. (a screw-up in a great guy)

I found your site thru "musings of a dinosaur. I would like to tell you about my med. mal experience:

I live in Pa. which supposedly has a medical malpractice "crisis"The problem is that, as you most probably are aware, it is a small handful of recidivist doctors who drive up the insurance costs for the rest of you.In 1979 Dr. Peter Jannetta, doing a "Janetta Procedure" (or MVD) for trigeminal neuralgia, paralyzed my face.I won't get into the lawsuit specifics - which includes 14 years in court and a forced settlement.I will say that this doctor had 13 suits brought against him. (That number is from many years back. I do not know if it is higher now.)I cannot speak to the other suits but the evidence in mine was overwhelming. In addition, Dr. Jannetta perjured himself about the risks.To my direct question he told me, "I promise you your face cannot be injured." On the stand Dr. Jannetta called facial paralysis an "unknown" complication.In 2 separate depositions Dr. Janneta called it a "major and common complication" of the MVD. * He did not then and continues still to not include this complication in his texts, web information, or speeches.The medical society at the local and state level, as well as the society of neurological surgeons, among others contacted, did nothing.As long as the state and the medical community refuses to take action against this small number who cause most of the malpractice incidents and lawsuits your costs will continue to rise. It is not the patients who are responsible for insurance premiums, or 'crisis'. The medical community need look no further than its own backyard.Thank you. Carol Jay Levyauthor A PAINED LIFE, a chronic pain journeymember, cofounder with Linda Misek-Falkoff, PWPI, Persons With Pain Internationalmember U.N. NGO group, Persons With Disabilities

The other fallout is that the trigeminal neuralgia association, whose mandate is to educate the public about TN, refuses to put my book, A PAINED LIFE, a chronic pain journey, the only book on the first person experience with TN, on their site. This is because of the 8 pages (out of 311) devoted to the entire Pittsburgh experience and Dr. Jannetta being a member of the board.

I've been coming here since I started my blog, and I haven't had the chance to thank you. I think I'll do that now. Even though it will take me some time to read through all these, I have already learned so much. You have been able to capture things about surgery that I have not been able to put into words.

lights n steel: thank you. I've been remiss in not blogrolling you, which I have now corrected. Reading your stuff takes me back. Not that I'd want to do it again; but the thrill of learning, of feeling myself getting there, is still very real when I recall it.

I have been reading your site for some time now- I would just like to say thankyou for your candidness and honesty. Like a number of your readers, I'm considering a career in medicine / surgery, and what you have built here is a terrific resource. I don't know whether you had anything half so useful when you were deliberating over prospective career paths.

I also particularly enjoy your writing style - your certainly have a gift for it. Could I be somewhat nosy and inquire as to your favourite books?

Paul: My reading is fairly eclectic, and I've been into non-fiction lately -- political stuff, like "Fiasco", which both fascinates me and drives me crazy. In fiction, I loved "Underworld" by Don Delillo, "Everything Is Illuminated" by Jonathan Safran Foer. A great non-fiction book is "Ship of Gold in the Deep Blue Sea." (that one is non-political, and non-crazy-driving.) I liked "The End of Faith," by Sam Harris. And I'm happy to read fun stuff, like Carl Hiasson, or Martin Cruz Smith, or Cormac McCarthy.

I went from your site to scalpelorsword.blogspot.com.I am saddened to see one of your readers refer to chronic ain patients as "dopers".You seem like a compassionate person as do many of your posters.If you think CP patients are dopers and chronic ain is just a sprain I hope you will take a read of my first chapter online and really learn what chronic pain can mean. Thank you.https://www2.xlibris.com/bookstore/book_excerpt.asp?bookid=18435

Hi Dr Schwab! i really miss reading new posts :/ few days ago, i was asked which doctor i admire or feel has caused an impression on me to start med school. from all your stories and your view about stuff, even if its "blog" oriented, i must conclude its you. So thanks for sharing this part of medicine, it's very encouraging to read some of what you have to say! (dont mean it to sound like im appleshining, im not ;p)

Everything you write is just so interesting and so readable - I am working through the full sampler. Just reached Appendicitis Four and it links to the same post as Appendicitis Three. I think you probably meant to link to

Ooh - I take a break from blogging for a while, and I come back to find you slowing down too? Aww c'mon Dr Schwab, here I was just about to pony up some cash for your book. Like the new post though - it's like a Contents page for your blog. (This BETTER not be the last post though - we med students can be very good at bugging people *ominous B-movie music*)

Dr. Schwab, I'm dying to know your opinion on this website: http://www.cosmeticsdatabase.com/It rates the toxicity level of all products being sold (because apparently the FDA isn't doing their job), and I really would like to know if it's reliable and accurate.

Ramona: I truly appreciate your words. Thanks. I wish it were possible for some sort of teleportation that would allow a face-to-face meeting of a cadre of medbloggers. What an event that would be! Meanwhile, I'm still at ebb phase. It's complicated. But then, isn't everything? One thing is clear: you are a good person.

Hospital politics is always interesting especially when it involves the safety of the patient. New study shows show hospitals lax in use of anti-microbials for cathetersA new national study indicates that fewer than one in three hospitals are using either bladder scanners or anti-microbial catheters to prevent urinary tract infection and less than one in 10 are using daily reminders that prompt doctors to “review the need for a catheter.”http://www.care-mates.com/blog/?p=61

Dr. Schwab... I looked at the cosmetic database. They looked thorough (if plethora of info equals to being one). Unfortunately, just because an ingredient is listed in the productm it doesn't mean the product will cause cancer, etc, etc. Different dose of these chemicals have to be taken into account. A bit too extreme in my opinion...

Dr. Schwab, It's been a while. Where, oh where are you. You know that death rumor seems to have gotten his muse back for him. He is typing up a storm over there.

I get in these blog funks also, and my current one has lasted for many months. But then again, I dont have near the importance of things to share that you do. I guess I could start another writing challenge and make your participation mandatory...:)You could write a part two of "Interlude." http://surgeonsblog.blogspot.com/2006/12/creative-interlude.html

Wait, wait. You blog every other day in March, and then April 1, 3, 4, 5, 6, 7, 8 and do a recap April 9 and the frequent fliers want you to up their doses and complain it's just not working well enough for them anymore and they just gotta have more of it, man? They don't mind if I laugh, right?

I don't comment much anymore, but I felt the need to let you know that I love your writing. It's poignant, gets to the emotional aspect quickly, and is delicate in its descriptive nature. I hope that you will write another book, something about life as a surgeon outside of residency - because your book left me with quite an impression. Just wanted to let you know that.

Your message bottle is now afloat in the vast blogosphere ocean. You are Message In a Bottle #247.Feel free to toss in a bottle whenever you feel the urge to send a message. The blog ocean is always open. You never know what might wash ashore.

Hi Dr S-I have so many posts to come back to and haven't as yet because i want to kick back and read them on son's laptop and savor them in comfort. :) I may still add my 1st 2 cents I was going to post in comments on your hell post.

Dr. Schwab,I wanted to let you know that my A&P class is over and I got an A!! It would have never happened if not for the surgeon who saved my life. Thank you for continuing with your blog (and I loved your "Moomump" post)! Now that I'm done with my class I get to read your book!!!!!!!!!!!

Wow...I had forgotten about the substance in some of these old posts...only to be reminded of it again! The one about the baby with pyloric stenosis was a chiller, indeed, for although the context was a completely different surgery, the idea of the terror of operating on such a tiny patient brought me totally back to the stories I heard from a neurosurgeon many years ago... The baby in question in that case was moi! And I suppose that never really goes away, even as they manage to save ever smaller babies these days.

And some of those memorable patient stories...wow! I've got a tough stomach, but that one about the huge amount of stool just about sent me over the edge! That, however, just reinforces that you're a good storyteller! I'll always come back for more...

Sid - had the chance to meet Dr. Trunkey at a local trauma conference. I just finished reading "Cutting Remarks" the night prior. The guy has been in surgical practice long than I've been alive. He's incredibly sharp of mind and of wit. Sure enough, he mentioned to us that you can't shine a sh*t.

I have been in hospital for over a month now and my doctors arecalling me an anomaly.

About two and a half months ago I started feeling a little 'offcolour'. I put it down to stress (of moving house recently andstarting a new job) and the fact that my partner (with whom I live)had been feeling a bit poorly over a weekend (minor stomach ailments,a little bit of diarrhoea) because that's how I had started to feel.

Within a week though I knew that it was a little more than that but Ihad just started my new job and wasn't going to take a day off sick ifI could help it.

By the end of the first week, I was losing my appetite and feelingnauseous and an intense itching had started.

Towards the end of my second week, I had not been eating more than afew bites of food at a time and had had diarrhoea, vomiting and had(unnoticed by me) begun to change colour to yellow.

On the Thursday of the second week, my partner bumped into me at atrain station on the way home from work and gave me a kiss. As wepulled apart, he started looking at me strangely saying that I lookedlike I had yellow eyes. Having no mirror, I waited 20 minutes andchecked it out in the mirror at home. Sure enough, I had a verydefinite tinge of yellow to my skin and the whites of my eyes weresomewhat worse.

That evening, I was vomiting everything that I was eating/drinkingincluding water.

The next evening, I went to an NHS walk in centre and they told methat I was jaundiced and to go home and sleep it off and I wouldreturn to normal colour within 4-6 weeks.

On Monday, after having an entire weekend of no food/water andvomiting bile, I decided that I had to take a day off work and went tomy doctor to arrange a blood test. (thankfully ignoring the firstdoctor's advice of 'going home and sleeping it off')

He examined me and found my liver to be tender to the touch and he putslight pressure on it and triggered off a gag reflex. I told him tostop otherwise I would be sick and he proceeded to put a little extrapressure on it and I threw up on the floor(!)

He told me to leave the surgery immediately and go and admit myself tothe nearest hospital and get myself put on a drip. He prescribed somepiriton (anti itching) and some anti sickness tablets. (My doctorsinformed me that had I not admitted myself to hospital, then I wouldhave died from dehydration/starvation within a week. I am looking at'multiple organ failure' because my liver, kidneys and gall bladderare under a huge amount of strain.)

Within hours of being put on the drip I was feeling better and all ofthe doctors that I had met until that point told me that had I 'gonehome and slept it off' I would have been dead by the end of the week.(My symptoms apparently wouldn't have changed much – I would have justgot more tired and more grumpy/irritable which I probably would haveput to the hot weather and then I would have gone to sleep and notwoken up.)

After the first week in hospital in isolation, my appetite wasincreasing dramatically and I was feeling a lot better. ( I was on astandard saline and glucose drip and all of my vitals were around thenormal mark.)

My daily blood test results were fluctuating but the only thing thathad really changed was the INR (the blood clotting) and that was veryslowly returning to normal.

By the end of the second week, I was transferred to the Royal Freewhere I was being quite sick. I was on N-Acetyl Cysteine and thedoctors had forgotten to mention that one of the side effects would besevere nausea.

They have done 2 X-rays, 2 Ultrasounds, 4 CT scans and one Liverbiopsy and they still are no closer to a solution. They want me tostay as a long term In Patient with no plans for treatment.

I am feeling physically better now and have done since about the endof the second week in hospital, I am eating lots of different foods(have been for a couple of 3 course meals in the last week, eatenentire roast dinners (and desserts) duck, chicken, pork, eggs, dairy,fish, fruit, drinking around 4 litres of pure water a day plus somemilkshakes and other fruit juices) I have been sick once recently andthat was due to overeating(!) I had had a three course meal and thendecided to continue to eat a huge pot of very acidic fruit.Unfortunately saw the fruit again which was, to be fair, my own sillyfault. (but oh, it tasted good!!)

My liver no longer feels tender to touch and I cant feel it with myfingers any more even though my doctors are telling me that itsgetting more inflamed. They are saying that some of my blood tests arevery slowly turning for the worse and they want me to stay in hospital'in case something happens/changes for the worse'

I am still in regular contact with a doctor from the first hospitalthat I was at who has taken a personal interest in my case because itsso unique.

I spend all day every day in hospital watching DVDs and reading books.I eat all of the meals that I am given (and sometimes more) I tookmyself off of the drip called N-Acetyl Cysteine because the doctorssaid that it wasn't actually doing anything except making me feelsick)

I am drinking, my bowels are moving freely of their own accord. I nolonger feel any nausea/sickness; don't have diarrhoea, don't feellethargic (I feel very energetic some days and most days am to befound roaming the hospital wearing a night dress and holding a laptopunder my arm in search of entertainment!)

After a month in hospital – they have tried me on a 6 day course ofsteroids and a drip called N-Acetyl Cysteine which lasted for about 5days neither of which has had an effect.

I was kept in contact isolation for a week because they thought that Iwas infectious and then realised that I wasn't. Then I stopped beingsick and have only been sick more recently as a direct side effect ofN-Acetyl Cysteine and over eating.

They did a liver biopsy (Through the jugular) and informed me thathalf of my liver cells were dead and the other half were newlyregenerated and at some point in the last 2 months my whole liver hadinexplicable died and began regenerating.

* I have not been in a position where I have had my drink spiked. * I do not take any recreational drugs and have never done any. * I do not/have never smoked. * I do not take the contraceptive pill. * I do not drink excessively and my monthly consumption of alcoholwould have to be less than 6 units (2/3 small bottles of cider) * I am not depressed/suicidal and did not try to commit suicide bytaking paracetamol/aspirin. * I do not generally take other forms of medicationherbal/prescribed or other. (I can remember the last medication that Itook, - a piriton for the itching before I came to hospital, a nasalspray to counteract what I thought was the beginning of a cold and ananti inflammatory (Ibuprofen) to counteract the swelling as a resultof the itching. (All of which were taken AFTER the initial symptomshad occurred.) * I do not eat shellfish usually, though I do buy small prawns andhave prawn cocktail jacket potatoes. * I have not been exposed to anyone with liver disease and thereis no history of it in anywhere in the family. * Though I travelled to Rio de Janeiro (Brasil) in January, I didnot pick up any exotic diseases and this is not a result of anythingthat I have picked up as nothing has shown up in my blood.

n.b Just as an after note – it has been noted by several differentpeople on different occasions(including nurses and two doctors) that Iappear to get less yellow towards the end of the day: my theory isthat I am drinking and eating so I am pushing things through my systemand the yellow fluctuates.

If you know or have any idea what this is, please please could you letme know because no one here has a clue!

My doctors are going a little crazy with my case and am now in the**** hospital in London. I am in a specialist liver ward andthey don't know how to treat me because they don't know that the causeis.

Please pass this onto anyone who may be able to help me because I cantbe the only person in the world to have this happen to them!

Just letting you know we sure miss you. Every morning we normally crowd around the noticeboard where your newest post has been placed. The profs wonder why we've all been on time the last couple of weeks :) Take care.

aussies: what a great comment! Thanks. I miss it, too. I don't rule out the return of my muse. Meanwhile, I love the idea of my work being posted in your school. The last time anything of mine was posted on a med school board, it was during the Vietnam war, when, just to freak people out, I sent a telegram in the name of the whole class congratulating President Johnson on the marriage of his daughter (my class -- myself included -- were quite vocal in opposition to the war.) The telegram indeed got lots of people angry. Amidst a gathering crowd I noticed my phone # was on the message. As soon as everyone left, I hastily took it down, with no one the wiser. Until now.

chris: thanks. I miss it, too. I do, of course, have many thoughts during this political crescendo, but I hesitate to pollute the blog any further with non-medical/surgical stuff. Meanwhile, I sometimes feel a slight stirring. As yet unrealized, and perhaps even unidentified.

I have to say, this is my favorite blog on the web. It's like delicious candy. I'm a medical student, and every time I feel annoyed or stressed, I just read some stories on here and it seems more worth it. Thank you for the insights and inspiration!

Just found your blog. Sometimes I wished I had chosen surgery...instead I don't use my hands at all! I also just read your blog about Dr. Ripoffs.In the field of psychiatry, it is even worse. There is even less 'standard of care', and people have no idea what happens behind these closed doors. Sometimes, I wonder if my patients think I am ripping them off when I recommend weekly therapy sessions. On the other hand, I can say with confidence, I am an above average psychiatrist, might even be a really good one (no way to tell, since my peers all close their doors.)Interesting to struggle with that, you know?

Hello Dr S...I read one of your blogs from 2007 on patient modesty and surgical procedures. I was relieved at the comments you made and I DO realize that the OR staff does not really give a crap that another naked body is set before them (I never did working in nursing homes) but when it is YOU, of course it is different. And as ridiculous as it sounds, I just can't get over it. I was obsessed with KNOWING all about the procedure to be performed and watched videos of it (adrenalectomy). I must say, most were quite boring and I had no idea what I was looking at. Looked like a bunch of goop. The best one was 10 minutes long, filmed in Chile, and was set to some snazzy music. It was boring too but I thought the addition of music was amusing.

Now that I have satisfied myself with viewing the actual proceure, where ports will be placed, and knowing none of it is in my hands, now I am worried about what happens after they knock you out up until the time they finish positioning and draping you. All pamphlets and such I have read tell you everything up until this point, then start discussing what happens when you wake up. I suppose most people don't care as long as they are asleep, but I do!! I have only ever had a D&C before and being naive about everything I never thought about these things the last time. This is a much more major operation however. Before I ask the dumb questions on OR prep (that maybe you don't even know or were never involved in being a surgeon) let me ask this. My surgery has been put off 2 times now because things (like my WBC level) was too high. Since it has been March of 2008 since I had an MRI should another one be done? No one has done one. How can I ask my doctor questions like this without sounding insulting about things like this and how many of these he has done, who will be in the OR and so on? I also have not seen the surgeon since my inital visit back in August. I had no information and no questions then. I have dozens now. He has not scheduled to see me again and the operation is nearing. Should I ask for an appointment?

Now on to the dumb questions!! After they knock me out, what happens? I am guessing it goes like this: A tube will be placed in my throat,my gown will be removed, a catheter will be inserted, I will be rolled on to my side as necessary for the procedure, I will be positioned, secured to the table, and draped? I really hope that happens rapidly if that is what happens. Is it? Also, I will no doubt have a catheter. Who inserts it, when and how do they do it when you are supine and asleep and can't bend your knees? Another dumb question: when they place me on my side I am unsure where my arms will be for this procedure, above my head or straight out? The reason I ask is because I am very large breasted and depending how I am placed, my breasts will be up in my neck. They are when I sleep and I usually either wear a bra or make sure my arm is between my neck and them. Will this be a problem for the OR team? Trying to figure out what to do with all this breast? Okay, you can chuckle at that but how can I breathe with all that extra tissue at my neck? I think that is it for now!! Any info you can give will be appreciated.

I think it makes excellent sense to schedule another appointment with your surgeon to go over your questions. He will be much more able to be specific than I, since there are variations in technique that might affect the answers. (And yes! I was a surgeon, which I'd have thought obvious from a review of my blog). Catheters are inserted, most often by a nurse (some surgeons insert them if it helps to speed things along) when you are supine. It's very easy to bend a patient's knees as needed. Where your arms are will depend on the chosen position: one thing I can say for sure is they will not be over your head. More likely tucked at your sides. Your breasts will not be an issue at all. In most ORs, the time you are uncovered is very brief, and in fact care is generally taken to expose only those parts necessary; ie, you won't likely be entirely uncovered ever.

Sid, I just wanted to let you know that I have awarded you one of my five "Surperior Scribbler Awards" your blog intrigued me to discover the world of blogging. So I knew that I had to present you with this award! I really appreciate your intellect!

I recently came accross your blog and have been reading along. I thought I would leave my first comment. I dont know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

Hi. I'm making a blog and post (maybe future ones as well) about med school and want being who are going, have been through, or willing be going input on my blog. http://bcann.wordpress.com. I hope you will follow my post and give any wisdom or rambling you my have on your mind. The more people I have the better my decision can be.

There is other stuff as well. If you enjoy it feel free to subscribe.

Thanks for taking the time to help a crazy college student.

P.S. If you know of any one else who would have some input, let me know. Also any blogs or site that would be of interest to me.

What a wonderful blog. It's too bad really that you don't seem to be updating it anymore. I followed a link here today and have enjoyed the posts in your sampler so much that I went to Amazon and ordered your book!

Hey there Dr. Schwab!I had been reading your blog for quite a long time and I must confess I simply love your posts! I just recently joined blogger and started a blog of my own (I am a Radiologic Technologist) so I hope you don't mind me adding this blog and keep checking on it from time to time to see if you made a miracle post. I am soon going to enter graduate school to become an Anatomist and I just can't pass up the chance to finally comment on a anatomy lover like yourself. Take care!

I stumbled across your blog on accident and have found it fascinating so far. I wanted to ask you about a really interesting coincidence however. I was reading these stories while my girlfriend watched "Gray's Anatomy" in the background. I shared the story about your partner getting sick with her and I swear to you, not 10 minutes later the next episode that came on was almost THE EXACT SAME STORY. One doctor is operating on another. The doctor as patient has an allergic reaction to the Chromic Sutures in his intestines causing them to harden. And of course he never knew about the allergy because he always used gloves... Was a remarkable coincidence just for the fact that I had just read your story. Is this kind of thing that common or is this story perhaps borrowed from you? Either way, its a fascinating blog and I hope you keep it up.

I'd actually heard about that episode from another reader; I think I referred to it somewhere in this blog.

Short answer: I don't know. The episode appeared well after I wrote about the incident, so it's certainly possible someone in Hollywood (or wherever) read it and, uh, borrowed it. I prefer to think so, anyway. I've never heard of another similar case.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.